If you are new or existing client of Log Cabin Animal Hospital please fill out this form ahead of time E-mail it to us (logcabinvet@gmail.com) or bring it with you, or fax it to us (317-570-8905) before you come in. This will save you and us a lot of time and we can get better prepared for your visit!

Is your address & phone number still correct? [ ] Yes [ ] No

If first visit, is this your first pet? [ ] Yes [ ] No

Are you aware pet insurance is available? [ ] Yes [ ] No

Chief Complaint or Reason for Visit:

Routine Vaccinations:

Has the pet been seen for same condition recently?
[ ] Yes [ ] No, How Long:

Are vaccinations up to date? [ ] Yes [ ] No

Is the pet spayed / neutered? [ ] Yes [ ] No

Has the pet been tested for internal parasites within past 6 months?
[ ] Yes [ ] No

Is the pet on heartworm preventive? [ ] Yes [ ] No

Have you seen the pet passing any worms? [ ] Yes [ ] No (Describe:

Any injury or illness in past 30 days? [ ] Yes [ ] No (Describe:

Does the pet have a history of having seizures? [ ] Yes [ ] No

Is the pet currently on any medications? [ ] Yes [ ] No (Describe:

Is the pet allergic to any drugs/medications? [ ] Yes [ ] No (List:

DIET:

How many times / day do you feed your pet? _______

PET TREATS:

Does the pet get table scraps? [ ] Yes [ ] No

Are there any food intolerances? [ ] Yes [ ] No

Did your pet eat this morning? [ ] Yes [ ] No

Appetite: [ ] Increased [ ] Normal [ ] Decreased

Weight: [ ] Loss [ ] Gain [ ] Stable

Water Consumption? [ ] Increased [ ] Normal [ ] Decrease

Bowel Movements? [ ] Constipated [ ] Normal [ ] Diarrhea (How long?

Urination? [ ] Increased [ ] Normal [ ] Increased Amount [ ] Increased Freq.

Straining to Urinate? [ ] Yes [ ] No

Vomiting? [ ] Yes [ ] No

Coughing? [ ] Yes [ ] No

Sneezing? [ ] Yes [ ] No

Gagging? [ ] Yes [ ] No

Any Listlessness? [ ] Yes [ ] No

Any Weakness? [ ] Yes [ ] No

Shaking Head? [ ] Yes [ ] No

Scratching? [ ] Yes [ ] No (Location:

Significant Hair Loss? [ ] Yes [ ] No [ ] Patchy [ ] Generalized [ ] Excessive Shedding

Flea Control Used? [ ] Frontine ? [ ] Advantage? [ ] Program? [ ] Other:

Scooting? [ ] Yes [ ] No

Unusual Lumps or Bumps? [ ] Yes [ ] No

Bad Breath? [ ] Yes [ ] No

Unusual Discharge? [ ] Yes [ ] No (Location:

Lameness? [ ] Yes [ ] No (Which Leg: [ ] RF [ ] LF [ ] RR [ ] LR

Difficulty Rising? [ ] Yes [ ] No

( After sleeping? [ ] Yes [ ] No; After Exercise? [ ] Yes [ ] No

Stiffness? [ ] Yes [ ] No

Any Behavioral Changes? [ ] Yes [ ] No (Describe:

Do you wish to be present while the pet is examined? [ ] Yes [ ] No

Anything else we need to know?